Dental Clinic Receipt Form
Dental Clinic Receipt Form
Please fill out this receipt form accurately to ensure proper documentation of services received and payments made.
Patient Information
Name:
Date of Birth:
Email:
Please provide your email address.
Phone Number:
Address:
Treatment Details
Date of Service:
Treatment Type:
Please check all that apply.
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Cleaning
-
Filling
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Extraction
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Root Canal
-
Crown
-
X-Ray
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Consultation
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Dentist Name:
License Number:
Payment Information
Total Cost of Treatment:
Tax (if applicable):
Discounts (if applicable):
Total Amount Paid:
Payment Type:
Please select one.
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Cash
-
Credit Card
-
Debit Card
-
Insurance
-
Cardholder Name (if applicable):
Last Four Digits of Card (if applicable):
Insurance Provider (if applicable):
Patient Acknowledgment
I, the undersigned, confirm that the services described above were provided to me, and I agree with the amount paid for these services.
Date:
Thank you for choosing our dental clinic!
If you need further assistance, feel free to reach out to us.
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